August 2, 2010

Reports of the Death of the NHS are somewhat exaggerated

While I agree with the principle behind Nick’s take on the removal of the cap on treating private patients in the NHS, I don’t think it can really stand in practice:

The NHS is supposed to treat all equally, regardless of wealth or status. It is important that the wealthy aren’t treated differently in the NHS if for no other reason than it is necessary for the future of the institution that everyone in this country feels that it is useful to them.

I’d like to think this was a realisable goal, but it seems that the pace of the cost of modern medicine renders it otherwise. Indeed, decades and billions of pounds have gone into improvement of the NHS, with the basic result that there’s still a widely held belief that it is a failing institution, when it really isn’t. From the same piece Nick refers to:

John Pelly, Moorfields’s chief executive, said: “Without profits [from our commercial business] our ability to invest in our clinical services would be seriously constrained … Particularly at a time when the financial constraints facing the NHS are going to be as severe as they are in the next three or four years, it’s going to be really important to the NHS that we can take advantage of the abolishing of the cap.”

Labour’s cap had meant most hospitals were unable to generate more than 2% from private income. The exception is the Royal Marsden, a leading cancer hospital which, thanks to history, has a cap of 31% – and a private income of more than £40m a year. The Marsden, Lansley says, is the “model” in his new-look NHS.

What we should also remember is that the NHS, for all intents and purposes, has been ringfenced in terms of the spending cuts. Yet despite this, there is still the £20,000,000,000 “black hole” referred to in the piece. This money has to come from somewhere, the alternative seemingly being an abandonment of these or other services.

I also differ (perhaps in ignorance) with Nick when considering the significance of the measure. Private health insurance exists already and thirteen years of a Labour government came nowhere close to changing that, so I suppose it’s to be an accepted reality. Why shouldn’t some of that action go to the NHS, so long as it maintains its core philosophy? Are there really legions of city bankers licking their chops at the prospect of paying the NHS and jumping ordinary man in street in the queue for elective surgery? No, they’ve almost certainly got private care already. Point is, the NHS is a system based on the rationing of resources. And given that these are very expensive resources, I doubt the net impact will be particularly large. If people bring their own resources to table, this isn’t necessarily bad:

Papworth Hospital, home to the first successful heart transplant in the UK, will soon be submerged into the new 135-acre Cambridge Biomedical Campus. Some of its operations are so complex – with costs running into £25,000 for 10 hours of surgery – that the NHS can only afford to pay for 80 a year.

It is to be hoped that with an infusion of private money, two things would happen in this scenario. Firstly, every operation beyond that 80th is paid for. Two, the profit generated from the charge would allow the NHS to provide more than that number. The scarcity of resources, as well as Waiting Lists (see below), are clearly of relevance here. Indeed, the existence of a person with the means to pay for the 81st such operation means that there is space for someone else within the yearly budget that might not otherwise have received the surgery. Of course, this may be arguing at the margins, but then I suspect that could be said of the whole debate. Still, I think it’s an important point that it’s not that the NHS only has the capacity for 80 such surgeries, it only has the money for that number.

There’s also this from the Guardian article:

However, academics caution that the rush to the market could lead not to NHS trusts profiting, but to them being undercut by ruthless foreign competitors or losing patients abroad. “What’s to stop US healthcare companies coming over here to poach patients. Or GPs sending patients to India for cheap operations? Or English hospitals raiding Scotland for sick people?” said Alan Maynard, professor of health economics at the University of York. “It could be a real mess.”

Sensible regulation, perhaps? As to the concern of the US poaching patients, I doubt this proposal changes things as they stand. As far as I’m aware, any paying customer is at liberty to fly over to the US and fork out for their treatment. That more don’t isn’t a testamant to the existence on a cap on NHS provision of private services than it is the sheer cost of US healthcare costs. I also think sensible regulation, such as it may be, is an answer for concerns over queue jumping and indeed most potential excesses.

What concerns me the most is that people less inclined towards nuance and analysis than my co-blogger might well suggest that this is privatising the NHS. Whenever I read such concerns, I reach for the figurative bourbon bottle and contemplate, in an equally figurative act, ending it all. Stuff like this is no more privatisation than the recent Affordable Care Act in the US was a move towards socialised medicine. I’ll say now that if you think anything the Tories are proposing will lead to privatised health care, then you don’t know what “privatised health care” actually looks like. I said the same thing with the US debate, only replacing the word “Tories” with “Democrats” and “privatised with “socialised”. This was the same for the outrage over the decision to hand over a large portion of the budget from one group of NHS employees to another, larger group of NHS employees to GPs.

I’m not sure what it is about health care that promotes such overheated rhetoric utterly shorn from an anchoring of reality. For me, this part of the article is as blatant a recourse to emotional blackmail as it is a non-sequiter:

The chief executive of one of the largest NHS hospitals, speaking anonymously, said chasing new markets might also see management spread “too thinly and lose clinical oversight”. “Look at Great Ormond Street. They expanded up the road to Haringey Council and the Baby P tragedy happened on their watch,” said the chief executive. The hospital in London provided paediatric staff to hospitals where Baby Peter was taken with fatal injuries that are now known to have been deliberately inflicted.

What the… Baby P? So if more private money is allowed into NHS, infants will be brutally beaten and killed by sociopaths? Waving the bloody shirt in this manner is as disingenuous when done in defence of the NHS as it was when engaging in slurs against it in the US. It’s utterly unhelpful and leads to a situation where we lose the ability to talk rationally about health care reform and all but accusing opponents of murder in the name of ideology.

The final point is Waiting List standard as a measure of NHS performance, which is something that perpetually bugs me. This has been measure de rigueur on which every battle seems to be fought (outside of Superbugs), but count me as someone who utterly mistrusts metrics that have been chosen as THE benchmark. David Simon puts it best:

You show me anything that depicts institutional progress in America, school test scores, crime stats, arrest reports, arrest stats, anything that a politician can run on, anything that somebody can get a promotion on. And as soon as you invent that statistical category, 50 people in that institution will be at work trying to figure out a way to make it look as if progress is actually occurring when actually no progress is.

This isn’t to say the system based on waiting lists hasn’t made progress, or that the Labour party didn’t. It’s merely to state that the abandonment of the waiting list as a dominant metric oughtn’t be mourned as a matter of course. It just doesn’t necessarily say everything about the state of the NHS.